biopsy ( oral pathology)
TRANSCRIPT
DR.ASIF IQBAL
2ND YEAR P.G
BIOPSY
WHAT IS A BIOPSY?
Biopsy is derived from a Greek word
(By-op-see) = Bio – meaning LIFE and
Opsy – TO LOOK(Vision)
Biopsy is the removal of tissue from a
living organism for the purpose of
microscopic examination and
diagnosis.
1870, Ruge and Joham Vert in Berlin introduced surgical biopsy as an essential tool for diagnosis.
1889, Emarch put forward an argument that confirmations should be made before surgeries for malignancies.
Williams halsted 1st introduced this principle in United States.
1941, study of exfoliated cells from female genital tract is done by Papanicolaou.
HISTORICAL PERSPECTIVE
BIOPSY : WHEN, WHY, WHERE?
CHARACTERISTICS OF LESIONS THAT RAISE THE
SUSPICION OF MALIGNANCY
Growth rate– lesion exhibits rapid growth
Bleeding— lesion bleeds on gentle
manipulation
Induration– lesion and surrounding tissue is
firm to the touch
Fixation– lesion feels attached to adjacent
structures
CHARACTERISTICS OF LESIONS THAT RAISE THE
SUSPICION OF MALIGNANCY
Erythroplakia—lesion is totally red or has
speckled red appearance
Ulceration—lesion is ulcerated or presents
as an ulcer
Duration— lesion has persisted for more
than 2 weeks
INDICATION FOR BIOPSY
Persistent hyperkeratosis changes in surface tissue (ex: lips or oral mucosa)
Lesion that interfere with local function (ex :fibroma)
Any inflammatory lesion that does not respond to local treatment after 10 to 14 days (that is after removing local irritant)
INDICATION FOR BIOPSY
Bone lesions not specifically identified by
clinical and radiographic finding.
Any lesion persists for more than 2 weeks
with no apparent etiology basis.
Any lesion that has the characteristics of
malignancy .
WHEN IS ORAL BIOPSY NOT
NEEDED? There is no need to biopsy normal structures.
There is no need to biopsy for inflammatory or infectious
lesions that respond to specific local treatments, as
pericoronitis, gingivitis or periodontal abscesses.
No incisional biopsies should be performed on suspected
angiomatous lesions.
Anticoagulant therapy
Over-whelming sepsis
Severe impaired lung function
Uncontrolled bleeding.
Uncooperative patient
Local infection near the site
CONTRA-INDICATIONS
To confirm a diagnosis made on clinical
findings.
To determine the treatment plan
Valuable self teaching diagnostic aid.
As a medical record
OBJECTIVES OF BIOPSY
CLASSIFICATION OF BIOPSY
According to the procedures applied, oral biopsies can be classified by:
a) Features of the lesion:
• Direct biopsy: when the lesion is located on the oral mucosa and can be easily accessed with a scalpel from the mucosal surface.
• Indirect biopsy: when the lesion is covered by an apparently normal oral mucosa.
b) Area of surgical removal:
• Incisional biopsy: consists of the removal of a representative sample of the lesion and normal adjacent tissue in order to make a definitive diagnosis before treatment.
• Excisional biopsy: is aimed at the complete surgical removal of the lesion for diagnostic and therapeutic purposes. This procedure is elective when the size and location of the lesion allows for a complete removal of the lesion and a wide margin of surrounding healthy tissue.
c) By the timing of the biopsy/ Clinical timing of sampling:
• Pre-operative
• Intra-operative
• Post-operative
d) Purpose of the biopsy.
Diagnostic Biopsy
Experimental Biopsy
TYPES OF BIOPSY
Surgical biopsy- Incisional Biopsy ,ExcisionalBiopsy and Punch Biopsy.
Fine Needle Aspiration Cytology(FNAC) and CT guided FNAC.
Exfoliative Cytology.
Brush Biopsy.
Frozen Section Biopsy.
Cone Biopsy.
Core Needle Biopsy.
Suction Assisted Core Needle Biopsy.
Laser Biopsy.
STEPS OF BIOPSY
1.SELECTION OF AREA OF BIOPSY
2.PREPARATION OF SURGICAL FIELD
3.LOCAL ANASTHESIA
4.INCISION
5.HANDLING OF SPECIMEN
6.SUTURING OF THE RESULTING WOUND
If a lesion is large or has
different characteristics in
various locations more than one
area may need to be sampled
INCISIONAL BIOPSY
Incision should extend from the ulceration out onto clinically normal
tissue
Grasp area to be removed with forceps and make an elliptical incision from the
centre out onto clinically normal tissue: wound after removal of incised tissue:
suturing completed
INCISIONAL BIOPSY
Indications:
Size limitations
Hazardous location of the lesion
Great suspicion of malignancy
Technique:
Representative areas are biopsied in a wedge fashion.
Margins should extend into normal tissue on the deep
surface.
Necrotic tissue should be avoided.
A narrow deep specimen is better than a broad shallow
one.
DISADVANTAGES:
1. Crush, splits and haemorrhage are the
artefacts most frequently found in
incisional oral biopsies.
2. Theoretical seeding of cancer cells into
the adjoining tissues.
Excisional Biopsy
The entire lesion with 2 to
3mm of normal appearing
tissue surrounding the
lesion is excised if
benign.
EXCISIONAL BIOPSY
An excisional biposy implies the complete removal
of the lesion.
Indications:
Should be employed with small lesions. Less than 1cm
The lesion on clinical exam appears benign.
When complete excision with a margin of normal tissue
is possible without mutilation.
EXCISIONAL BIOPSY
Technique:
The entire lesion with 2 to 3mm of normal
appearing tissue surrounding the lesion is
excised if benign.
FOR MUCOCELE LESIONS – CAREFUL EXCISIONAL BIOPSY
PUNCH BIOPSY
Advantages :
Ease of technique
Sutures may not be required if small diameter punch
May produce a more satisfactory specimen in bound down tissues (e.g. hard palate)
Drawbacks:
May not be adequate for biopsy of deeper pathology
May be difficult to biopsy freely movable tissues (e.g. soft palate, floor of mouth)
CORE BIOPSY
Fine needle biopsy has been established
as a safe procedure and is routinely
performed under local anaesthesia. Many
pathologists believe that for histologic
study, core tissue is more useful than
cytologic material
Core needle biopsy (CNB) has emerged as an important
sampling method in the diagnosis of musculoskeletal
tumours
FINE NEEDLE ASPIRATION CYTOLOGY
It is the “Technique of aspiration of cells/
fluid/ tissue fragments using a fine needle for
examination under a microscope”
ADVANTAGES
1. The technique is relatively painless, produces speedy results.
2. It is an inexpensive technique.
3. It requires little equipment.
4. The technique can be done as an out patient or a bed side procedure.
5. There is no problem with wound healing.
6. The technique is readily repeatable
INDICATIONS
1. Non palpable lesions, or area difficult to biopsy but can be localized by CT, MRI, Ultrasound.
2. To rule out vascular lesions prior to open surgery.
3. In cases where Biopsy is contraindicated on medical background.
4. Used as a diagnostic screening test at community level for head and neck masses.
5. Indicated for known tumors to assess effect of treatment.
6. Used to obtain tissue for specific studies.
FINE NEEDLE WITH
ASPIRATION
FOR MAJOR SALIVARY GLAND/LYMPH GLAND LESIONS FNAC MAY BE
USEFUL
BRUSH BIOPSY
Diagnosis of oral epithelial dysplasia has
traditionally been based upon histopathological
evaluation of a full thickness biopsy specimen
from lesional tissue.
It has recently been proposed that cytological
examination of “brush biopsy” samples is a non-
invasive method of determining the presence of
cellular atypia, and hence the likelihood of oral
epithelial dysplasia.
Exfoliative Cytology
It is a quick and simple procedure, is an important alternative to biopsy in certain situations. In exfoliative cytology, cells shed from body surfaces, such as the inside of the mouth, are collected and examined. This technique is useful only for the examination of surface cells and often requires additional cytological analysis to confirm the results.
DANGERS OF BIOPSY
Spreading of infection
Haemorrhage
Infection
Operative trauma
INJECTION
For red & white lesions include both red &
white area
For Vesiculobullous lesions
Fluid is more representative. Intact vesicle or bulla
should be biopsied.
ULCERS
Include
margin,deep part of
ulcer and site of
maximal clinical
activity.
AVOID Superficial
ulcers & necrotic tissue
BIOPSY DATA SHEET
PATIENT DATA
HISTORY
CLINICAL DESCRIPTION
NATURE OF BIOPSY
RADIOGRAPHS & PHOTOGRAPHS
DISCRIPTION OF BIOPSY SPECIMEN
BIOPSY REPORT
IT SHOULD INCLUDE DIAGNOSIS AS
WELL AS A COMPLETE MICROSCOPIC
DESCRIPTION
ARTIFACT = Artificial (man made) product
Artifacts are alteration in the tissue morphology
that results from various forms of mechanical,
chemical, or thermal insult to the tissue specimens
removed for diagnostic purposes, anywhere from
fixation to processing to staining. Numerous types
of artefacts can affect the biopsy specimen.
CLASSIFICATION
PRE BIOPSY ARTIFACTS:
They are introduced prior to the collection of the tissue
BIOPSY ARTIFACTSInjection of L.A. into the lesion.
Injection Artifacts
Improper handling of the tissue
Errors during manipulation of tissue
Forceps/ Squeeze Artifact
Problems in orienting excised tissue
Heat Artefact(Fulguration Artifact)
Foreign Bodies or Starch Artifact.
INJECTION ARTIFACT
IMPROPER REMOVAL
HEAT ARTEFACT
FORCEPS ARTIFACT
CRUSH ARTIFACT
SPLIT ARTIFACT
It is not easy to procure a good biopsy
specimen, nor is it very difficult, but the
procedure must be carefully planned and
carried out.
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